COVID-19 and the Need for Action on Mental Health

By Chara Malapani, MD, PhD

The dire consequences of the global pandemic have been difficult to escape, let alone ignore. The devastating effects of the coronavirus — from physical symptoms to economic complications — have made themselves apparent in headline after headline, week after week, for months that have felt like decades. Yet beneath the apparent grim news, the United Nations (UN) is warning that the coronavirus presents still another menace that health officials must not overlook. The coronavirus pandemic “has the seeds of a major mental health crisis,” the UN warned in a policy briefing last week, calling for substantial investment in support services. 

"The COVID-19 virus is not only attacking our physical health; it is also increasing psychological suffering: grief at the loss of loved ones, shock at the loss of jobs, isolation and restrictions on movement, difficult family dynamics, uncertainty and fear for the future," UN Secretary-General António Guterres said in a video message launching a mental health policy brief last week. 

The UN policy release emphasizes that “decades of neglect and underinvestment in addressing people’s mental health needs have been exposed by the COVID-19 pandemic” in a call for ambitious commitments from countries in the way they treat mental illness, amid a potential global spike in suicides and drug abuse. “Even when the pandemic is brought under control, grief, anxiety and depression will continue to affect people and communities” said Guterres. He urged the international community to do much more to protect all those facing mounting mental pressures. He also emphasized that “the mental health and wellbeing of whole societies have been severely impacted by the COVID-19 pandemic and are a priority to be addressed urgently.” 

Launching the UN policy brief “COVID-19 And The Need for Action On Mental Health,” Guterres highlighted how those most at risk today, were “frontline healthcare workers, older people, adolescents, children, women and those with pre-existing mental health conditions and those caught up in conflict and crisis. We must help them and stand by them.” He also stressed that people caught in fragile humanitarian and conflict settings risk having their mental health needs overlooked entirely.Because of the size of the problem, the vast majority of mental health needs remain unaddressed.  The response is hampered by the lack of investment in mental health promotion, prevention and care before the pandemic.

Dr. Kathy Pike, Director of the Columbia-WHO Center for Global Mental Health in the Department of Psychiatry stated, “We need to remember that COVID-19 is likely to have a long shadow, especially given the economic impact on so many individuals and the enduring disruptions to daily life for so many.” Dr. Geoffrey Reed, also a member of the Columbia faculty in the Department of Psychiatry and the New York State Psychiatric Institute (NYSPI), played an important role in the background work that led to the release of the new UN policy on mental health and COVID-19. Dr. Reed’s network of collaborators around the world “have reported a range of major disruptions in mental health services, including massive premature discharge of psychiatric patients, prohibited family visits, cancellation of services, restricted transfer of patients between hospitals, reduction of out-patient follow-ups, lack of routine mental health care. If not addressed and reversed, these factors will contribute to a COVID-related mental health crisis.” 

Dr. Reed also emphasized that “health professionals around the world are reporting substantial job-related stress. This is related to having to manage their own fears of being infected or infecting others, but it is exacerbated by inconsistent information or misinformation from health systems or governments, a lack of organizational and community support, and experiences of social stigmatization and even violence. Job-related stress may be so severe that a substantial proportion leave their jobs or professions. Mental health professionals’ work has been profoundly disrupted by the COVID-19 pandemic. Some have been redeployed to provide medical services or respond to the mental health needs of COVID-19 patients or their families. Others continue to work on mental health teams but in the context of institutions whose activities and priorities have shifted dramatically. Many have had to make a rapid pivot to providing services via telehealth technologies (such as videoconferencing or telephone), that allow physical distancing from patients. A mental health workforce that is in severe occupational distress will be less able to provide quality services to patients with mental health conditions, who face barriers to care that have been exacerbated by the COVID-19 pandemic.”

Dr. Reed, along with Dr. Pike and Columbia colleague Dr. Tahilia Rebello, is leading a global longitudinal study that examines the impact of COVID-19 on the clinical practice and well-being of global mental health professionals, including factors that may help to protect against distress and burnout. Participants are members of the Global Clinical Practice Network. Hosted by the Columbia-WHO Center for Global Mental Health, the Global Clinical Practice Network is the largest practice-based and most international research network ever established, consisting of nearly 16,000 mental health professionals from 159 countries.”

The importance of these initiatives is paramount given the fact that “a long-term upsurge in the number and severity of mental health problems is likely,” according to the UN policy release. “Mental health services are an essential part of all government responses to COVID-19” the UN Secretary-Generalconcluded, urging “governments, civil society, health authorities and others to come together urgently to address the mental health dimension of this pandemic.” Guterrescalled on governments in particular to announce ambitious commitments on mental health at the upcoming World Health Assembly.

Addressing the question of the imminent and long-term mental health crisis, Dr. Pike said, “We don’t need to have a mental health crisis if we prioritize mental health and integrate mental health services in the evolving economic, social and health policies for COVID-19.  I know that is a big “if,” but the bottom line is that a mental health crisis is preventable if we have the political will.  We fully support the UN Secretary General Policy Brief on how to make this a reality. The opportunity for us at Columbia is to help make this happen through policy, research, training and service.”

The message of the UN release was echoed by Dévora Kestel, Director of the Department of Mental Health and Substance Use at the World Health Organization (WHO), who warned of a “looming mental illness crisis, the result of the isolation, the fear, the uncertainty, the economic turmoil,” brought on by the pandemic. She added that “the mental health and wellbeing of whole societies have been severely impacted by this crisis and are a priority to be addressed urgently.” 

At the Columbia-WHO Center for Global Mental Health, Dr. Pike’s group has been working with business leaders to help them prioritize mental health and wellbeing in their workplaces. “In partnership with AXA, a global insurance company, we are developing a toolkit for leaders and managers to support employee mental health in the context of COVID-19.  We know that recognizing and responding effectively to employee mental health needs – from widespread anxiety and fears to less common, but more severe concerns related to trauma, suicide and substance use – will be central to successfully navigating this pandemic,” said Dr. Pike.

Dr. Pike stressed that “based on what we have learned from other recent epidemics and pandemics—SARS, MERS, Ebola, H1N1—we need a thoughtful and differentiated approach to addressing the mental health needs of affected individuals. More population-based efforts can go a long way to support and serve those feeling elevated levels of stress, anxiety and depressive symptoms.  But we also need systems in place to serve those who have more intense and acute psychological needs. Many services can be provided remotely, but we need to be sure that telehealth services are working well for those with severe mental disorders and other populations with more complex needs.”. 

The advances and challenges of telehealth were also addressed by Dr. Reed: “Telehealth services offer one solution to mitigating the burden on mental health services, but there are a variety of practical, technical, legal and ethical issues that have to be addressed. While there is a growing evidence base on the effectiveness of telehealth for numerous mental disorders and patient populations, a limited number of clinicians have training and experience in using these technologies. Reasons for not adopting telehealth have included lack of access to training, adequacy of internet connectivity, jurisdictional issues, reimbursement limitations, ethical concerns and perceptions of inferiority of clinical care. Now, there has suddenly been a massive adoption of these solutions so that mental health professionals can continue to care for their patients. We need to rapidly deploy more systematic training as well as offer secure platforms and technical support, as Columbia is doing. We also need to evaluate the effectiveness of these services and identify areas and populations that require alternative methodologies.”

According to the UN policy release, while innovative ways of providing mental health support had been implemented in the past few months, it hasn’t gone far enough to deal with the needs of the vast majority because of the historical underinvestment in this area before the pandemic. It pointed out that depression and anxiety cost the global economy more than $1 trillion a year before the coronavirus pandemic and that globally, there is fewer than one mental health professional for every 10,000 people. This is despite the fact that depression affects 264 million people around the world. Yet, the UN said countries spend just 2% of their healthcare budget on mental health on average. 

As such, the UN recommended that countries develop and fund national plans that shift mental health care away from institutions to community services. In addition, they should ensure coverage for mental health conditions in health insurance packages and build the human resource capacity to deliver quality mental health and social care in communities.

The UN report cited research from 2018 by the Lancet Commission on global mental health and sustainable development, which showed that mental health problems exist on a continuum from mild to severe. The UN said that the COVID-19 crisis influenced where people were situated on the continuum, and “many people who previously coped well, are now less able to cope because of the multiple stressors generated by the pandemic.” Meanwhile, those who already had a mental health condition may experience a “worsening of their condition and reduced functioning.” The UN report also referred to a study conducted in Ethiopia in April, which estimated that 33% of people were showing symptoms of depression, thought to be three-times higher than before the crisis. The UN also said that to cope with the stress of the coronavirus pandemic, people may resort to alcohol, drugs, smoking or spending more time on potentially addictive activities like online gaming. It mentioned another study that found a fifth of Canadians aged 15-49 had been drinking more during the pandemic. 

It is encouraging that as a result of the COVID-19 crisis, a strategic shift in mental health policy is recommended by the UN: “The historic underinvestment in mental health needs to be redressed without delay to reduce immense suffering among hundreds of millions of people and mitigate long-term social and economic costs to society.”

The UN recommendations for a Public Policy solution would: 

1. Apply a whole-of-society approach to promote, protect and care for mental health
2. Ensure widespread availability of emergency mental health and psychosocial support
3. Support recovery from COVID-19 by building mental health services for the future. All affected communities will need quality mental health services to support society’s recovery from COVID-19, and this requires investment in the following:

• using the current momentum of interest in mental health to catalyze mental health reforms, for example by developing and funding the implementation of national services re-organization strategies that shift care away from institutions to community services;
• making sure that mental health is part of universal health coverage, for example by including care for mental, neurological and substance use disorders in health care benefit packages and insurance schemes; 
• building human resource capacity to deliver mental health and social care, for example among community workers so that they can provide support;
• organizing community-based services that protect and promote people’s human rights, for example by involving people with lived experience in the design, implementation and monitoring of services.
• Research needs to be part of recovery efforts (it is important to understand the extent of the mental health consequences - including the neurological and substance use impact- of COVID-19 and the social and economic effects of the pandemic, directly consulting with the affected populations. Such research will likely strengthen advocacy efforts for mental health. Rapid knowledge acquisition will require establishment of research priorities, research coordination, open-data sharing and funding.

Chara Malapani, MD, PhD is faculty member of the Psychosis Unit at the Division of Translational Imaging at NYSPI, served as director of the Neuroimaging Cognition Laboratory and the Temporal Cognition Laboratory, Division of Cognitive Neuroscience, Department of Psychiatry at Columbia University, and has thirty years experience in the field of Cognitive Neuroscience.